Commentary: China's changing health system: Implications for sexual and reproductive health

Assessment of progress towards sexual and reproductive health (SRH) in China requires the consideration of changes in separate health and family planning systems, as well as consideration of the transition from a command economy to a socialist market economy, led by a highly centralised political system, in the last three decades. Reform of the health system in the 1980s and 1990s encouraged marketisation of health services, while the rural Cooperative Medical Scheme (CMS) functioning during the 1960s and 1970s collapsed. Both health and gender equity were seriously damaged. The majority of the rural population paid for health services out of pocket, which impoverished many. Poor rural women suffered disproportionately because their access to basic reproductive health services was sharply curtailed (Fang, 2004). The Third Plenary Session of the 16th Central Committee of the Chinese Communist Party, held in fall 2003, attempted to ‘rebalance’ an overly economy-centred growth process towards a greater focus on social development (Fewsmith, 2004). This adjustment produced a number of health policies and programmes supporting greater equity. A new rural CMS was initiated in 2003 that has since provided basic medical insurance, covering maternal health care and institution-based delivery for rural populations, and by 2012 it covered 98% of the intended beneficiaries (Ministry of Health, People's Republic of China, 2013). HIV testing and counselling, antiretroviral treatment, prevention of vertical transmission and care for AIDS orphans have been provided to all citizens free of charge since 2003 (Ministry of Foreign Affairs of the People's Republic of China, United Nations System in China, 2010). In 2008, the government began to provide financial subsidies for rural women in the central and western areas to deliver in hospitals, and in 2009, this policy was expanded to cover all rural areas, resulting in a rapid increase in the rate of institutional delivery (Ministry of Health, People's Republic of China, 2012). Also, in 2009, a new policy provided the framework for health sector development in future decades, including free provision of selected public health services for all citizens, covering maternal and child health care, and other SRH services such as screening for cervical and breast cancers (Ministry of Health, People's Republic of China, 2012). The family planning system actively responded to the 1994 International Conference on Population and Development (ICPD) by implementing a quality of care project, beginning in 1995, to enable couples to freely choose contraceptives beyond male and female sterilisation and IUDs, and later scaling the project up for the whole country (Kaufman, Zhang, & Xie, 2006). The focus shifted from family planning services alone to the inclusion of other SRH services. In 2010, for example, to prevent congenital birth defects, this system offered free screening for sexually transmitted infections (STIs), such as syphilis and gonorrhoea, to married couples planning a pregnancy. Tremendous improvement in women's reproductive health has been achieved in the last three decades. Institutional delivery reached 95% for the whole country in 2009 (Ministry of Health, People's Republic of China, 2012). The maternal mortality ratio (MMR) and the under-five child mortality rate declined from 110 and 46, respectively, in 1990, to just over 26 and 15.6 in 2011, bringing China very close to achieving the Millennium Development Goals (MDGs) 4 and 5 (WHO, UNICEF, UNFPA, & World Bank, 2010; ‘Chen Zhu,’ 2012). Poorer areas, not only richer ones, have experienced substantial maternal health improvements. The contraceptive prevalence rate of married couples has held firm at over 85% from 1980 through 2010, and the HIV infection rate is stable at a low level (Ministry of Foreign Affairs of the People's Republic of China, United Nations System in China, 2010; Wang, 2012). All of this progress is due, at least in part, to health system improvements. Despite progress, however, the rapidly changing health system faces both old problems and new challenges. While the gaps in SRH between rural and urban regions are narrowing, rural-to-urban migrants, mostly of reproductive age, still do not enjoy equal access to SRH services because they are not registered as urban residents. The average caesarean-section rate in China is just over 46%, much higher than the WHO's recommendation (Bai, 2013), due to both supply- and demand-side factors. Adolescents and unmarried youth have huge unmet needs for contraceptives and other SRH services. The result is high and repeated abortion rates in these groups (Qian, Tang, & Garner, 2004). Finally, despite efforts by the government to address the male-to-female sex ratio imbalance at birth, it continues to remain highly skewed at 118 male births to 100 female births in 2012 (Li, 2012). Most achievements in SRH in China have been made via vertical and top-down programmes. This approach can quickly mobilise resources to solve targeted problems, but it can also ignore issues not yet on the prioritised list. In 2013, the health and family planning systems were combined, and local-level integration is ongoing. The implications for SRH are uncertain. The reform could lessen the pressure of population control and provide SRH services in an integrated manner. Or, it may reduce access to free contraceptives, because basic public health services do not currently include contraceptives. Concrete measures should be taken to avoid such a result. For this to happen, women must be empowered to bring their concerns into the agenda, and thereby achieve universal access to quality SRH services, and improved health outcomes.

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